Strategic priorities for TB control in Bangladesh, Indonesia, and the Philippines - comparative analysis of national TB prevalence surveys.

BACKGROUND: Philippines, Indonesia, and Bangladesh are three high tuberculosis (TB) burden countries in Asia which account for 18% of the estimated global TB incidence (1.8 million) and 15% of TB related deaths (192,000). In 2017 alone, approximately 785,000 of the incident TB cases in these countries remained missing, including diagnosed but not notified. METHODS: We reviewed the published data from the most recent TB prevalence surveys conducted in Bangladesh, Indonesia, and the Philippines. The prevalence rates established by the surveys were used to estimate the disease burden of these countries for 2017. The Global TB Report 2017 and World Health Organization's (WHO) global TB database were sourced for collection of incidence and notification data by age groups and types of TB to estimate prevalence to notification gaps 2017. RESULTS: According to the surveys, the estimated prevalence rates of bacteriologically confirmed TB and smear-positive TB are 287 and 113 for Bangladesh (2015-16), 759 and 256 for Indonesia (2013-14) and 1159 and 434 for the Philippines (2016) per 100,000 population over the age of 15 years. The overall national TB prevalence estimates for all forms is 260 for Bangladesh, 660 for Indonesia, and 970 for the Philippines (2016). Compared with the incidence rate, the proportion of total notified cases is 67% for Bangladesh, 52% for Indonesia, and 55% for the Philippines. Bangladesh has been able to detect almost 100% of the prevalent pulmonary TB, while Indonesia and Philippines have detected only 30 and 22% of these infectious cases respectively. Although notification has been improving over the years, there is no impact on the incidence rate since a large proportion of the undiagnosed cases, and delayed diagnosis continue to feed the transmission process. CONCLUSION: The surveys have provided data that is critical for developing realistic strategies for these countries to eliminate TB. In general, this paper recommends interventions for strengthening diagnosis of pulmonary TB, implementing targeted communication programs and active case finding to reduce patient level delays, expanding public-private partnership to increase access to TB services, using rapid diagnostics, and providing social protection for vulnerable populations. These measures can accelerate these countries' progress towards achieving End TB goals.

Malaria elimination using the 1-3-7 approach: lessons from Sampov Loun, Cambodia.

BACKGROUND: Cambodia has targeted malaria elimination within its territory by 2025 and is developing a model elimination package of strategies and interventions designed to achieve this goal. METHODS: Cambodia adopted a simplified 1-3-7 surveillance model in the Sampov Loun operational health district in western Cambodia beginning in July 2015. The 1-3-7 approach targets reporting of confirmed cases within one day, investigation of specific cases within three days, and targeted control measures to prevent further transmission within seven days. In Sampov Loun, response measures included reactive case detection (testing of co-travelers, household contacts and family members, and surrounding households with suspected malaria cases), and provision of health education, and insecticide-treated nets. Day 28 follow up microscopy was conducted for all confirmed P. falciparum and P. falciparum-mixed-species malaria cases to assess treatment efficacy. RESULTS: The number of confirmed malaria cases in the district fell from 519 in 2015 to 181 in 2017, and the annual parasite incidence (API) in the district fell from 3.21 per 1000 population to 1.06 per 1000 population. The last locally transmitted case of malaria in Sampov Loun was identified in March 2016. In response to the 408 index cases identified, 1377 contacts were screened, resulting in the identification of 14 positive cases. All positive cases occurred among index case co-travelers. CONCLUSION: The experience of the 1-3-7 approach in Sampov Loun indicates that the basic essential malaria elimination package can be feasibly implemented at the operational district level to achieve the goal of malaria elimination in Cambodia and has provided essential information that has led to the refinement of this package.

Cost-effectiveness of malaria elimination in Sampov Loun Operational District, Cambodia.

BACKGROUND: Over the past decade, Cambodia has seen a significant decline in its malaria burden. The government has established the goal of eliminating malaria in the country by 2025. With PMI/USAID support, Cambodia is implementing a package of interventions as part of its efforts. This assessment aimed to describe the cost of malaria elimination activities in Sampov Loun Operational District (OD) between July 2015 and March 2018, to describe the cost per malaria case detected under PMI programming, and to estimate the incremental cost-effectiveness of the elimination programme per Plasmodium falciparum (Pf) or P. vivax (Pv)/Pf mixed case averted under the Cambodia Malaria Elimination Programme (CMEP) and the U.S. President's Malaria Initiative. Opportunity costs of government workers were also assessed to understand the theoretical cost of sustaining this programme through government efforts alone. MATERIALS AND METHODS: We conducted an empirical micro-costing analysis based on elimination activities alone using CMEP internal project implementation data and corresponding epidemiologic data from July 2015 to March 2018 and empirical findings from implementation to date. We then constructed a cost model in Microsoft Excel using empirical data and used a cost-effectiveness decision tree to describe programme effectiveness in the first three years of implementation and to estimate efficacy for the subsequent year. RESULTS: The total cost of malaria elimination activities in Sampov Loun OD from July 2015 to March 2018 was $883,096. The cost per case of malaria detected in 2017 was $1,304. Including opportunity costs for government staff from July 2015 to March 2018, the total cost was $926,000. Under continued CMEP implementation, the projected future total cost of the program would be about $110,000 per year, or $0.64 per Sampov Loun resident. The incremental cost-effectiveness of the elimination programme was $28 for every additional Pf or Pv/Pf mix malaria case averted, compared to the no-CMEP proxy. CONCLUSION: CMEP activities are cost effective compared to the no-CMEP proxy, as shown through an incremental cost-effectiveness of $28 for every additional Pf or Pv/Pf mix malaria case averted. The total cost of the project is 0.93% of the total per capita spending on health in Cambodia and about 5% of all government health expenditure. Continuing investments in malaria will be needed at national level for stewardship and governance and at local level for ensuring programme readiness in case of malaria outbreaks.

Decentralized, Community-Based Treatment for Drug-Resistant Tuberculosis: Bangladesh Program Experience.

BACKGROUND: Bangladesh is a highly populous country where the prevalence of drug-resistant tuberculosis (DR-TB) is growing. With the rapid increase in DR-TB notifications through GeneXpert technology, it was imperative to come up with a new treatment strategy that could keep up with the increase of patients diagnosed. INTERVENTION: Intervention was designed to support national transition of DR-TB management of World Health Organization-approved long course (20-to-24-month regimen) treatment from a hospital-based approach to the decentralized model of community-based programmatic management of DR-TB (cPMDT). In close coordination with the Ministry of Health and Family Welfare and National TB Program, patients were initiated into treatment at hospitals and then transferred to community-based care. A cadre of directly observed therapy providers supported treatment at the household level, supervised by the outpatient DR-TB teams. METHODS: We conducted a descriptive pre- and post-intervention study of all 1,946 DR-TB patients enrolled in treatment nationwide between May 2012 and June 2015. Data were collected from hospitals, patient cards, district records, and diagnostic laboratories through the National TB Program. Intervention results were assessed in comparison with the baseline (2011) indicators. RESULTS: During the intervention period, treatment enrollment of 1,946 diagnosed DR-TB patients through the national program increased from 50% in 2011 to 100% in 2015. The delay between diagnosis and treatment initiation decreased from 69 days in 2011 to 6 days in 2014. Most (95%) of the patients completed all scheduled follow-up smear and culture tests. By the sixth month of treatment, 99% of patients had negative smear conversion and 98% had negative culture conversion. The treatment success rate increased from 70% in 2011 to 76% in 2015 at the end of the intervention period. The results also indicate a decline between baseline and end line from 14% to 9% for patients died, 14% to 10% for loss to follow-up, and 1.7% to 0% for treatment failure. CONCLUSIONS: Community-based management is an effective approach for increasing access to quality-assured DR-TB treatment. Using existing structures and resources, the intervention demonstrated that favorable treatment outcomes can be achieved and sustained by treating patients with DR-TB at their homes.